What is the treatment for a urinary candidiasis (fungal infection) in males?

Treatment of Urinary Yeast Infection in Males

For symptomatic Candida cystitis in males, treat with oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks, and remove any indwelling urinary catheter if present. 1

Initial Assessment and Risk Stratification

Before initiating treatment, determine whether the patient requires antifungal therapy at all:

• Most asymptomatic candiduria does NOT require treatment unless the patient is neutropenic, a very low-birth-weight infant, or undergoing urologic procedures 1, 2
• Remove predisposing factors first (indwelling catheters, unnecessary antibiotics) as this alone clears candiduria in approximately 50% of asymptomatic patients 1, 3
• High-risk patients requiring treatment include those with neutropenia, symptoms of cystitis/pyelonephritis, or planned urologic manipulation 1

Treatment by Clinical Presentation

Symptomatic Cystitis (Bladder Infection)

First-line therapy:

• Oral fluconazole 200 mg (3 mg/kg) daily for 2 weeks for fluconazole-susceptible organisms 1
• Catheter removal is mandatory if feasible 1

Alternative therapy for fluconazole-resistant organisms:

• For C. glabrata (fluconazole-resistant): Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days OR oral flucytosine 25 mg/kg four times daily for 7–10 days 1
• For C. krusei: Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days 1
• Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be considered only for refractory fluconazole-resistant species 1

Pyelonephritis (Kidney Infection)

First-line therapy:

• Oral fluconazole 200–400 mg (3–6 mg/kg) daily for 2 weeks for fluconazole-susceptible organisms 1
• Eliminate urinary tract obstruction (nephrostomy tubes, stents) - remove or replace if feasible 1

Alternative therapy for resistant organisms:

• For fluconazole-resistant C. glabrata: Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days with or without oral flucytosine 25 mg/kg four times daily 1
• Flucytosine monotherapy (25 mg/kg four times daily for 2 weeks) can be considered as a weaker alternative 1
• For C. krusei: Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days 1

Critical caveat: If pyelonephritis is accompanied by suspected disseminated candidiasis, treat as candidemia with higher doses and longer duration 1

Urinary Fungus Balls

Management approach:

• Surgical intervention is strongly recommended 1
• Systemic antifungal therapy: Fluconazole 200–400 mg (3–6 mg/kg) daily OR Amphotericin B deoxycholate 0.5–0.7 mg/kg daily with or without flucytosine 25 mg/kg four times daily 1
• Local irrigation with Amphotericin B (25–50 mg in 200–500 mL sterile water) through nephrostomy tubes if present 1

Patients Undergoing Urologic Procedures

Prophylactic treatment:

• Oral fluconazole 400 mg (6 mg/kg) daily OR Amphotericin B deoxycholate 0.3–0.6 mg/kg daily for several days before and after the procedure 1

Key Clinical Pitfalls

Common mistakes to avoid:

• Do not treat asymptomatic candiduria in immunocompetent patients - this leads to unnecessary antifungal exposure and potential resistance 1, 2
• Echinocandins and newer azoles (except fluconazole) do not achieve adequate urinary concentrations and should not be used for urinary tract infections 2, 3
• Bladder irrigation alone has high relapse rates and should only be used as adjunctive therapy for refractory resistant organisms 1
• Failure to remove catheters significantly reduces treatment success - catheter removal is as important as antifungal therapy 1, 4

Why Fluconazole is Preferred

Fluconazole achieves the highest urinary concentrations of any antifungal agent, is highly water-soluble, and is primarily excreted unchanged in urine, making it ideal for urinary tract infections 2, 3. The oral formulation achieves the same urinary levels as intravenous administration 3.